Long COVID (post-COVID-19 condition): the AU general practice guide

Long COVID — formally termed post-COVID-19 condition (PCC) — has emerged as one of the largest chronic illness burdens arising from the pandemic. With Australia having experienced multiple Omicron waves affecting millions, the number of Australians living with Long COVID is substantial. The 2023 Australian Parliament inquiry “Sick and tired: Casting a long shadow” documented significant gaps in recognition, research funding, and clinical infrastructure.

The WHO Delphi consensus case definition (2021) describes PCC as symptoms persisting or arising from three months after probable or confirmed SARS-CoV-2 infection, lasting at least two months, and not explained by an alternative diagnosis. NICE NG188 additionally distinguishes ongoing symptomatic COVID-19 (4–12 weeks) from post-COVID-19 syndrome (≥12 weeks). The RACGP’s dedicated post-COVID-19 clinical resources and RACP Long COVID position (2023) are the primary AU guidance documents.

Long COVID is a heterogeneous biological condition — not a psychological one. Acknowledging this clearly with patients is therapeutically important: dismissal, disbelief, or poorly evidenced advice to “just push through” causes harm. At the same time, the evidence base remains evolving, requiring honest communication about what is and is not currently known.

A. Core clinical — the AU general-practice framework

The clinical phenotypes

Long COVID does not present as a single syndrome. Four overlapping phenotypes drive most presentations:

1. Fatigue and PEM subgroup — dominant fatigue, post-exertional malaise, cognitive impairment (“brain fog”); substantial overlap with ME/CFS criteria
2. Cardiopulmonary subgroup — dyspnoea, chest tightness, palpitations, reduced exercise capacity; POTS and myocarditis are the priority diagnoses to exclude
3. Autonomic dysfunction / POTS subgroup — postural tachycardia, pre-syncope, dizziness on standing, exercise intolerance
4. Cognitive and neuropsychiatric subgroup — brain fog, concentration difficulties, memory impairment, mood and anxiety disorders, anosmia or parosmia

History

A thorough history covers: date and severity of the acute COVID-19 episode (PCR or rapid antigen confirmed or probable); symptom-by-symptom inventory across fatigue, PEM, cognition, sleep, mood, dyspnoea, palpitations, chest pain, orthostatic symptoms, anosmia/parosmia, hair loss, joint or muscle pain, gastrointestinal symptoms; symptom timeline (continuous from acute or after a lucid interval); functional impact on work, activities of daily living, and relationships.

PEM/PESE screening using the DSQ-PEM tool is essential — ask specifically: “Do you experience a worsening of symptoms after physical, cognitive, or emotional exertion that would previously have been easily tolerated?” If yes, PEM is present and management pivots entirely to pacing.

Screen for mood and anxiety (PHQ-9, GAD-7) — comorbidity is near-universal in PCC and warrants its own treatment, not dismissal as the “explanation” for all symptoms.

Examination

• Vital signs with postural measurements — sitting and standing HR and BP at 0, 3, 5, and 10 minutes: the NASA Lean Test identifies POTS (≥30 bpm sustained rise in HR without orthostatic hypotension) and orthostatic hypotension
• Respiratory — RR, SpO₂ on room air at rest and after 1-minute chair-stand ×10 (desaturation ≥3% warrants further cardiopulmonary investigation)
• Cardiac — rhythm, murmurs, oedema, JVP; ECG
• Neurological — cranial nerves including smell test, cognition via MoCA, coordination

Investigations

Baseline RACGP/NICE NG188 panel: FBC, UEC, LFT, CRP, ferritin, B12, vitamin D, thyroid function tests, fasting glucose/HbA1c, lipids, urinalysis, ECG. This panel addresses treatable contributors — anaemia, hypothyroidism, diabetes, vitamin deficiencies — and documents baseline organ function.

Cardiac workup (if chest pain, palpitations, or exercise-disproportionate fatigue): troponin if acute chest pain; echocardiogram; cardiac MRI if troponin is elevated or echo is abnormal — definitive for myocarditis and pericarditis.

Respiratory workup (if dyspnoea, cough): CXR; spirometry with lung volumes and DLCO; CTPA if VTE suspected.

Autonomic workup: NASA Lean Test or 10-minute active stand in general practice; tilt-table test for formal POTS confirmation (cardiology or autonomic clinic); 24-hour Holter for palpitations.

Cognitive testing: MoCA in clinic; formal neuropsychological assessment if cognitive impairment is disabling.

Avoid ordering broad autoimmune panels, “Lyme panels”, or microbiome testing without a specific clinical rationale — these produce false-positive results, escalate anxiety, and have no therapeutic consequence in the absence of other clinical features.

B. Evidence appraisal — what works and what does not

What is recommended

Pacing and the energy envelope — the cornerstone of management for PEM-positive patients. Work within approximately 40–50% of perceived capacity; avoid the boom-bust cycle of overexertion followed by prolonged crash. Use a symptom diary and heart-rate monitoring to guide activity levels. NICE NG206 (2021) explicitly endorses pacing over activity-based rehabilitation in ME/CFS-spectrum illness, directly applicable to Long COVID with PEM.

Graded exercise therapy (GET) is NOT recommended for PEM-positive Long COVID. NICE NG206 withdrew the recommendation for GET following a systematic review of harms. The RACGP and RACP 2023 position align with this position. In patients without PEM who have deconditioning-dominant illness, symptom-titrated rehabilitation (not GET) can be appropriate — but any re-emergence of PEM is an immediate signal to halt and revert to pacing.

POTS management per Raj et al POTS position statement (2020): non-pharmacological first (compression stockings 30–40 mmHg waist-high, salt 8–10 g/day, water 2–3 L/day); pharmacological if inadequate (propranolol 10–20 mg twice daily, or ivabradine 2.5–5 mg twice daily — often better tolerated with less fatigue and hypotension); midodrine or fludrocortisone for orthostatic hypotension subset.

Symptomatic pharmacotherapy: low-dose amitriptyline 10–25 mg nocte for sleep and pain (off-label); melatonin for sleep; SSRIs/SNRIs for comorbid mood and anxiety; paracetamol and short-course NSAIDs for pain and headache.

CBT for chronic illness adjustment, mood, sleep, and anxiety — framed explicitly as improving quality of life, not as treating the underlying biological condition.

Olfactory training for parosmia and anosmia: four odorants (rose, eucalyptus, lemon, clove) twice daily for at least 12 weeks has evidence from Hummel et al. Laryngoscope (2009).

Vaccination reduces the risk of Long COVID in subsequent SARS-CoV-2 infections by approximately 50% per Catalá et al. Nature Communications (2024). Continue per ATAGI advice.

What is not recommended

NICE NG188 and the RACGP are clear that the following are not guideline-supported for Long COVID outside clinical trials: prolonged corticosteroids; antivirals (other than for acute COVID-19 in eligible patients); hyperbaric oxygen; intravenous vitamin C, NAD, or glutathione; ivermectin; and low-dose naltrexone as PCC-specific treatment. Each may have ongoing trials, but no current guideline endorsement exists.

C. Accessing the evidence base — a patient communication note

Patients with Long COVID frequently encounter a large online ecosystem of unproven or potentially harmful treatments. Part of the GP role is providing a framework for evaluating evidence: helping patients understand what “a case series” means versus a randomised trial, and why the harms of certain approaches (particularly GET in PEM-positive patients) are real.

Acknowledging the patient’s experience as valid, the illness as real and biologically grounded, and the frustration at limited treatment options — while being honest about the evidence — maintains the therapeutic alliance and reduces drift toward costly and potentially harmful alternatives.

D. Australian operations

MBS billing. Long COVID consultations typically run as Level C or D (items 36 and 44). GPCCMP (items 965 and 967) is appropriate for patients with prolonged disabling PCC — the chronic condition criteria are met. Telehealth (items 91790, 91891) is valuable for severely affected patients. MHCP (items 2715/2717) for the near-universal comorbid mood and anxiety component. Multidisciplinary case conferencing (items 735–747) for complex cases coordinating multiple specialties. Cardiac pathology (ECG item 11700, echocardiogram item 55126) and respiratory pathology (spirometry item 11506) are rebated under standard specialist referral.

State-funded Long COVID clinics. Referral to a multidisciplinary Long COVID service is appropriate for patients with significant functional impairment not responding to GP-led management. Current major public clinics (as of June 2026):

• Victoria — Royal Melbourne Hospital Long COVID Service; Alfred Health Long COVID clinic
• NSW — St Vincent’s Hospital Sydney Long COVID clinic; Liverpool Hospital; LHD-based services
• Queensland — Princess Alexandra Hospital Long COVID clinic
• WA — Fiona Stanley Hospital Long COVID service
• SA, TAS, ACT, NT — variable; GP-led pathways with specialist input

PBS. Propranolol, fludrocortisone, and amitriptyline are general schedule. Ivabradine is general schedule (PBS authority codes apply for heart failure indications; POTS is off-label — private prescription may be required). Midodrine is Authority Required Streamlined for postural hypotension. SSRIs and SNRIs are general schedule. Melatonin (Circadin 2 mg) is Restricted Benefit for adults 55 and over with primary insomnia — private prescription required for Long COVID sleep use outside this indication. Low-dose naltrexone is not PBS-listed for any indication — private compounded prescription typically $30–80/month.

NDIS and Centrelink. NDIS eligibility requires functional impairment likely to be permanent or lasting — acceptance is variable. JobSeeker with partial capacity to work certificate is appropriate for significantly impaired patients unable to work full-time. Detailed functional documentation from GP, allied health, and specialist is critical for Centrelink reports.

E. Special populations

Women. Long COVID has a higher prevalence in women (approximately 2:1 female to male ratio) with peak incidence at ages 35–55. Hormonal interactions — particularly perimenopausal oestrogen fluctuation — may modulate symptom severity. Consider menopause assessment alongside Long COVID workup in this age group.

Healthcare workers. Occupational COVID-19 exposure may be covered by workers’ compensation in some states. Document acute infection timing, occupational exposure, and the subsequent PCC development explicitly in the clinical record.

Children and adolescents. Paediatric Long COVID exists but is less common and tends to remit more quickly than in adults. POTS is proportionally more prominent in adolescent presentations. School return planning requires coordination with parents, school support staff, and paediatric services.

Pre-existing ME/CFS or chronic fatigue. Prior post-infective fatigue syndrome is a risk factor for more severe Long COVID. Management follows ME/CFS-informed protocols — pacing, POTS management, sleep, and mood.

When to escalate

Refer or escalate when:

• Suspected PE, VTE, myocarditis with elevated troponin, or syncope — emergency department
• Suicidality — acute mental health pathway
• POTS not responding to conservative management — cardiology
• Persistent dyspnoea, abnormal spirometry, or imaging abnormalities — respiratory medicine
• Parosmia not resolving with olfactory training >6 months — ENT
• Disabling cognitive impairment — neurology
• Suspected MCAS spectrum — immunology
• Significant functional impairment not improving with GP management — Long COVID multidisciplinary clinic referral

Send with referral: symptom timeline from acute COVID-19, PEM characterisation, NASA Lean Test results, baseline pathology, ECG, imaging, vaccination history, functional impact summary, and prior treatment trials.

What this article is and is not

This is general health information drawn from RACGP post-COVID clinical resources, NICE NG188 and NG206, WHO PCC case definition, RACP Long COVID position, and peer-reviewed evidence from AHA, Catalá et al., and Raj et al. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about investigation, management, referral, and escalation are made with your own GP and treating clinicians.

For AU consumer resources: HealthDirect — Long COVID, Long COVID Australia, Emerge Australia. For mental health support: Beyond Blue 1300 22 4636, Lifeline 13 11 14, 13YARN 13 92 76.

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Sources cited

1. RACGP — Post-COVID-19 conditions clinical resources
2. NICE NG188
3. NICE NG206
4. WHO — Post-COVID-19 condition clinical case definition 2021
5. RACP — Long COVID position 2023
6. Stevens AHA Scientific Statement 2022
7. Raj SR et al — POTS position statement 2020
8. Catalá M et al — Vaccination and Long COVID (Nat Commun 2024)
9. Hummel T et al — Olfactory training (Laryngoscope 2009)
10. Long COVID Australia
11. Emerge Australia
12. HealthDirect — Long COVID
13. Australian Parliament — Long COVID inquiry 2023